CM Chest Pain History Flashcards
What does a diagnostic approach to chest discomfort consider?
Uses a complex understanding of common and life-threatening diagnoses to sort through possibilities effectively.
Common life threatening diagnoses from chest pain?
Myocardial Infarction, Pulmonary Embolism, Aortic Dissection.
What is a differential diagnosis?
A list of diagnostic possibilities that arise after taking a history.
What should a differential diagnosis include?
Leading diagnostic possibilities, plausible alternatives, life-threatening possibilities.
What are the cardinal chief complaints for heart disease?
Chest discomfort Shortness of Breath Lower Extremity Edema Palpitations Syncope Cough
Why is the patient centered aspect of a history important?
Pure gold, unbiased info
Leads you might miss
Establish rapport
Being present
What are the differences in using OLDCARTS and Pivotal Quesstions?
OLDCARTS helps you gather information to begin to make a diagnosis
Pivotal questions help you rule in or rule out other possible diagnoses
What is a syndrome?
A syndrome is a set of symptoms, that may be common to several diseases
What structures may be responsible for chest discomfort?
Heart, Aorta, Lung, Pericardium/Pleura, Stomach, Brain, Skin
What are the causes of Coronary Atherosclerosis?
Cause: Narrowing of coronary artery leading to mismatch of oxygen supply and oxygen demand
Myocardial Ischemia leads to pain
Compare and contrast Stable and Unstable plaques?
Atherosclerosis is divided into two groups: Stable and Unstable plaques
Stable plaques result in fixed obstruction of a vessel and cause stable angina, which is constant at rest and worsens only with exertion
Unstable plaques result in obstruction of multiple vessels, and cause unstable angina/acute coronary syndrome
Compare and contrast how Angina can present?
Angina may be stable or unstable
Stable plaque = Stable angina = localized + painless at rest + worsens with exertion
Unstable plaque = unstable angina = diffuse pain + painful at rest + worsens with exertion
How do pain and exertion support or oppose Angina?
Treating Angina as pain that is truly associated with the heart, and not another compartment:
Increased discomfort due to exertion + relief with rest = Angina due to increased Oxygen demand worsening pain
How does the type of pain support or oppose Angina?
Dull chest pain = Angina since visceral organs like the heart are innervated by the PNS and give off dull pain signals
Sharp chest pain = Not Angina because somatic organs other than the heart are innervated by the SNS and give off sharp pain signals
How does radiation to other areas support or oppose Angina?
Collateral arm and/or jaw pain on either side suggests Angina due to shared innervation and referred pain
What are they key clinical features of Angina?
Brought on by exertion Relieved by rest or Nitroglycerin Describes as dull, pressure May be described as indigestion Never lasts seconds, rarely lasts days Can radiate to jaw/arms/neck Can be associated with nausea/vomiting
What is Aortic Dissection?
A tear in the Media of the Aorta leading to the formation of a dissection flap
Can compromise blood flow or rupture Aorta entirely
What are the key clinical features of Aortic Dissection?
Sudden onset Tearing or ripping pain Very severe History of hypertension Radiates to the back
What is a Pulmonary Embolism?
Blood clot travels to pulmonary vasculature and lodges, compromising blood flow
How does Shortness of Breath support or oppose Pulmonary Embolism?
Shortness of Breath increases the likelihood of pulmonary embolism, since a blood clot in an artery in the lung will cut off blood flow to that area, lowering the amount of oxygenated blood in circulation and causing shortness o f breath
No Shortness of Breath = Pulmonary Embolism less likley
How does pain support or oppose Pulmonary Embolism?
Sharp pain = Pulmonary embolism since a clot that lodges in an artery causes inflammation that damages Pleural tissue, which is innervated by the SNS and detected as sharp pain; additionally, clot stretches the artery causing SNS sharp pain
Dull pain generally opposes Pulmonary Embolism but could occur if blood flow to the Left Ventricle is cut off
How does pain and breathing support or oppose Pulmonary Embolism?
Pulmonary Embolism worsens with inspiration because it is a form of pleuritic pain
What are the key features of Pulmonary Embolism?
Pleuritic pain (sharp, worse on inspiration)
Shortness of breath
Hemoptysis
DVT due to recent travel
What is Tension Pneumothorax?
A rare but life threatening cannot miss diagnosis, occurs when air is trapped inside the Pleural cavity and displaces the mediastinal structures
What are they clinical features of Tension Pneumothorax?
May be related to previous trauma
Not found in history
Absence of breath sounds on one side, the displaced side Severe shortness of breath
What is Pericarditis?
Inflammation of the pericardium, secondary to other etiologies such as viral infection
How does pain support or oppose Pericarditis?
Sharp pain = support Pericarditis because the Pericardial sac is innervated by the SNS which transmits sharp pain signals
How is Pericarditis differentiated from other Pleural Pain?
Pericarditis is very localized to the heart, whereas other pleural pains are more diffuse or in other organs
What are the key clinical features of Pericarditis?
Sharp pain, that may vary with respiration Varies with position Can radiate to the back Can be associated with fever ECG changes often present
What is Esophageal Rupture?
Aka Boerhaave’s Syndrome, rupture of the esophagus
What are the key clinical features of Boerhaave’s Syndrome?
Found in setting of severe vomiting and severe chest/upper abdominal pain
Free air in mediastinum on X-ray
What is GERD?
Gastroesophageal Reflux Disease is stomach acid refluxing into the esophagus causing pain
What are the key clinical features of GERD?
Burning pain described as indigestion
Associated with meals
Can occur at night, while lying down
What is Peptic Ulcer Disease?
Peptic ulcers = ulcers in lining of stomach or duodenum
Caused by H. pylori
Heartburn or indigestion symptoms
Can be better or worse with meals
